The development of technique and materials has allowed

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1 A Novel Technique for the Reconstruction of Infected Full-Thickness Chest Wall Defects Wassim Raffoul, MD, Michael Dusmet, MD, Michel Landry, MD, and Hans-Beat Ris, MD Divisions of Plastic and Reconstructive Surgery, Thoracic Surgery, and Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland Background. Chest wall resection and reconstruction can be performed with minimal mortality and excellent functional and cosmetic results using synthetic meshes, methylmethacrylate, or other substitutes. However, these techniques are less easily applicable if chest wall resections have to be performed for infections. Methods. We report a novel technique for this purpose using a modified latissimus dorsi flap harvested in continuity with the thoracolumbar fascia. The vascularized fascia was sutured into the chest wall defect, providing a stable base for the muscular component of the flap. Three patients requiring large full-thickness resections of the anterolateral chest wall for chronic infections were treated accordingly, two presenting with chronic radionecrosis and osteomyelitis and one with chest wall invasion by pulmonary aspergillosis. Results. There were no intraoperative or postoperative complications and immediate extubation was possible in all 3 patients without the need for postoperative ventilation or tracheotomy. Healing of the infected chest wall was observed in all 3 patients. Postoperative cinemagnetic resonance imaging revealed concordant movements of the replaced segments without evidence of paradoxical motion during inspiration and expiration. Conclusions. This technique is easy and safe. It allows a stable and satisfactory reconstruction after large anterolateral full-thickness chest wall resections of infected, previously irradiated tissues, using only wellvascularized autologous tissue. (Ann Thorac Surg 2001;72:1720 4) 2001 by The Society of Thoracic Surgeons The development of technique and materials has allowed full-thickness chest wall resection and reconstruction to be performed with low mortality and morbidity [1]. The most common technique to reconstruct a full-thickness resection is to replace the skeletal defect with a sandwich of methylmethacrylate between two layers of Marlex mesh or Bard mesh (Bard, Galway, Ireland) and to fill the soft tissue defect with a myocutaneous flap if required. This method offers excellent chest wall stability and good cosmesis [2, 3]. The popularity of this technique is related to its reliability and ease of construction. When radionecrosis is found, the wound is almost invariably infected and the use of nonresorbable synthetic material in the reconstruction should be avoided if possible [4]. This recommendation also applies when chronic infection is present. Reconstruction with a musculocutaneous flap has been performed in such cases [5, 6]. However, this alternative may provide insufficient stability leading to paradoxical breathing, which can cause respiratory problems [5]. We describe a novel modification of the latissimus dorsi flap, which provides a stable base to the reconstruction while using only healthy, well-vascularized autologous tissue. Accepted for publication July 10, Address reprint requests to Dr Dusmet, Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; michael.dusmet@chuv.hospvd.ch. Material and Methods Surgical Technique Complete excision of the infected, irradiated soft tissues and the underlying chest wall was performed in all 3 patients. All resection margins were through macroscopically healthy tissue. A right musculocutaneous latissimus dorsi flap based on the thoracodorsal vascular pedicle was harvested in continuity with the thoracolumbar fascia (Figs 1 and 2). This fascial structure measures approximately cm. It is the continuation of the deep and superficial aponeurosis of the latissimus dorsi muscle. A rich vascular network is readily visible on its undersurface. These two layers of viable vascularized fascia were sutured circumferentially and under slight tension to the edges of the skeletal defect with interrupted Prolene sutures (Ethicon, Somerville, NJ). The muscular or musculocutaneous component of the flap was used to fill either the soft tissue defect of the chest wall or a residual space after lung resection. With lung resection, the flap was transposed into the chest and the fascia was brought up and sutured into the chest wall defect. The donor incision was closed primarily in all patients. Follow-up All patients were followed by clinical and radiologic examinations after the operation. The duration of postoperative ventilation and the need for tracheotomy was 2001 by The Society of Thoracic Surgeons /01/$20.00 Published by Elsevier Science Inc PII S (01)

2 Ann Thorac Surg RAFFOUL ET AL 2001;72: RECONSTRUCTION OF INFECTED FULL-THICKNESS CHEST WALL DEFECTS 1721 Fig 1. Planning of incision for harvesting the flap (patient 2). (1 scapula; 2 skin flap; 3 iliac crest; 4 spine; 5 thoracolumbar fascia.) recorded, as well as signs of persistence of infection of the chest wall or the underlying lung. In addition, the patients underwent assessment of the chest wall integrity Fig 3. The planned full-thickness resection of an infected, irradiated segment of the chest wall in patient 2. on an outpatient basis after their discharge from the hospital by use of cine-magnetic resonance imaging (MRI) as reported previously [3]. Fig 2. The harvested flap including the thoracodorsal fascia (patient 2). (1 scapula; 2 skin flap; 3 iliac crest; 4 the latissimus dorsi muscle; 5 the thoracolumbar fascia.) Fig 4. Reconstruction of the chest wall defect by suturing the fascia to the edges of the skeletal defect (patient 2). (1 base of the neck; 2 lower extent of the previous sternotomy incision; 3 thoracolumbar fascia; 4 latissimus dorsi muscle.)

3 1722 RAFFOUL ET AL Ann Thorac Surg RECONSTRUCTION OF INFECTED FULL-THICKNESS CHEST WALL DEFECTS 2001;72: Fig 5. Cinemagnetic resonance imaging with coronal sections through the reconstructed chest wall of patient 2 during inspiration and expiration demonstrating concordant chest wall motion and the absence of paradoxical motion during respiration. This figure shows the superposition of the images acquired dynamically during forced inspiration and expiration. Patient 1 A 72-year-old woman underwent a right modified radical mastectomy in 1990 for breast cancer. In 1996, she had a partial resection of two ribs and the adjacent part of her sternum as a result of local chest wall recurrence, followed by postoperative radiotherapy because of microscopically positive resection margins. The chest wall was reconstructed with a Mersilene mesh (Ethicon, Brussels, Belgium) and the soft tissues were closed primarily. Two weeks later a purulent discharge was noted and antibiotics were prescribed. A chronic purulent discharge developed through a sinus tract and reoperation with removal of the infected mesh and wide resection of the anterolateral chest wall including part of the sternum was performed. The defect measured cm and was closed by use of a right myocutaneous latissimus dorsi flap in continuity with the thoracolumbar fascia. Patient 2 A 55-year-old woman underwent a median sternotomy for evaluation and biopsy of a nonresectable mediastinal tumor (adenocarcinoma) in 1997 followed by radiotherapy of the mediastinum and interferon administration. The mediastinal mass resolved completely. In 1999, she presented with bleeding and a chronic purulent discharge from the upper part of her sternotomy wound (Fig 3). A computed tomography scan demonstrated radionecrosis and osteomyelitis of the manubrium sterni and possible fistulization of the innominate vein into the infected sternum. A complete resection of the upper 10 cm of the sternum, the sternoclavicular joints and adjacent cartilages of the first four ribs and all irradiated soft tissues was performed en bloc with the innominate vein, leaving a cm defect. A right latissimus dorsi musculocutaneous flap with the thoracolumbar fascia was prepared and sutured in place as described above (Fig 4). Patient 3 A 45-year-old woman had a stage I breast cancer, which was treated by lumpectomy and irradiation of the affected breast. One year later, she presented with acute myelogenous leukemia, which was treated with chemotherapy. Invasive pulmonary aspergillosis involving the right upper and middle lobes infiltrating the adjacent anterior chest wall developed, despite amphotericin B administration. As further chemotherapy and autologous bone marrow transplantation was planned, she underwent a right upper and middle lobe resection with en bloc resection of the infected segment of the anterior chest wall, leaving a cm chest wall defect. The right latissimus dorsi and thoracoclumbar fascia were harvested and the chest wall defect was reconstructed as described above. However, in this situation intrathoracic muscle transfer was performed to buttress the bronchial stumps and to fill the residual space after superior bilobectomy to avoid recurrent intrathoracic infection in this neutropenic patient, and the fascia was therefore brought up from inside and was then sutured to the edges of the chest wall defect. Because the skin and subcutaneous tissue were not involved, no soft tissue reconstruction of the chest wall had to be performed. Results All patients were extubated at the end of the procedure without the need for reintubation or tracheotomy during follow-up. All patients had an uneventful postoperative course and all wounds healed primarily despite the neutropenic status in patient 3. There was no sign of persistent infection of the chest wall and no infection of the underlying lung. No paradoxical breathing could be detected in the area of the reconstruction in any of the 3 patients, and there was no clinically relevant respiratory limitation in any patient. All patients had a right-sided latissimus dorsi flap harvested with no limitation in arm or shoulder function. The cosmetic result was also excellent, especially as compared with the preoperative aspect of the anterior chest wall in patients 1 and 2. These patients had a cine-mri during inspiration and expiration that confirmed the clinical impression of concordant movement of the reconstruction and demonstrated the absence of paradoxical motion (Fig 5). Comment Different methods have been proposed for the reconstruction of the chest wall after full-thickness resections of tumors involving the anterior or anterolateral aspect of the chest wall [7, 8]. Among these, the latissimus dorsi musculocutaneous flap covering a skeletal reconstruction using a sandwich of methylmethacrylate cement between two layers of Marlex mesh has become one of the most popular techniques. The latissimus dorsi musculocutaneous flap was developed by Tansini in Padua at the end of the 19th century to replace the large defects left by radical mastectomies

4 Ann Thorac Surg RAFFOUL ET AL 2001;72: RECONSTRUCTION OF INFECTED FULL-THICKNESS CHEST WALL DEFECTS 1723 [9]. Later the latissimus dorsi flap was rediscovered and used to cover full-thickness chest wall defects. Many modifications have been proposed to add rigidity to the flap to avoid or minimize paradoxical respiratory motion, such as segments of fascia lata [10] or segments of ribs as free grafts [11, 12], which were sutured to the edges of the skeletal defect. Since the 1950s, many synthetic materials such as Teflon (DuPont, Parkersburg, WV), Dacron (C.R. Bard, Haverhill, PA), and nylon meshes or sheets have been developed, as have acrylic resins and titanium implants. A combination of methylmethacrylate resin sandwiched between two layers of Marlex mesh has offered excellent functional results [3], is easy to construct, and does not require harvesting of autologous material. These techniques allow the skeletal defect to be reconstructed, and musculocutaneous flaps are then used to fill the soft tissue defect. The drawback of these techniques is that all rely on nonvascularized tissues or implants to provide rigidity. The risk of reinfection is therefore high if these techniques are used in the reconstruction of infected and irradiated tissues. Patients 1 and 2 in this report had an area of the anterior chest wall that was the object of full-thickness bacterial infection of heavily irradiated tissues. Patient 3 had an invasive aspergillus infection of the lung eroding into the previously irradiated anterior chest wall. The skeletal defect in all 3 patients measured from 10 to more than 15 cm in diameter after full-thickness debridement had been performed and was located in the anterior aspect of the chest wall, including the sternum in 2 patients. The defect was predominantly anterolateral in 2 patients and included both sternoclavicular joints in the third patient. These findings mandated a stable reconstruction in all three cases. Reconstruction of the skin and soft tissues was required in 2 patients. Inert or devascularized implants were avoided for skeletal reconstruction. We also thought that a musculocutaneous flap would not provide sufficient stability of the chest wall to prevent atelectasis, ventilation-perfusion disturbances, and infection of the irradiated underlying lung. Indeed, Larson and McMurtrey [5] used a musculocutaneous flap for this purpose and noted important functional problems in the initial postoperative period with significant paradoxical movement of the flap. Autologous fascia lata would provide nonvascularized tissue that would be prone to infection and the use of vascularized ribs would have increased the risk of local and respiratory complications. A single latissimus dorsi flap was therefore designed that would include the thoracolumbar fascia, as well as muscle and skin if required, to overcome these drawbacks. The use of the thoracolumbar fascia has been described to cover abdominal defects [13] and for functional muscular transfers to the upper limb [14] or to cover large spinal defects after meningomyelocele repair [15]. This structure is the inferior extension of the superficial and deep aponeurosis of the latissimus dorsi muscle and has a common blood supply as illustrated by a rich capillary network on its surface arising from the adjacent muscle. When this double layer of fascia was sutured to the edges of the skeletal defect, it provided a tough, stable base for the soft tissue reconstruction if required. In our series, the musculocutaneous component of the flap was then used to replace the soft tissue defect of the chest wall in 2 patients. In the third patient, the muscular component of the flap filled the residual space after bilobectomy for invasive aspergillosis in a neurotropenic patient. All 3 patients had an uneventful recovery with immediate extubation after the operation and without need for tracheostomy or repeated bronchial toilet by bronchoscopy. There was no significant clinically evident paradoxical motion of the reconstruction in the early and late postoperative period in any of our patients. Cine- MRI examination, a dynamic image of the chest acquired during deep breathing, confirmed the excellent stability of the reconstruction. This stability was provided by the fascial component of the flap, which was sutured under slight tension to the edges of the skeletal defect. The length, consistency, and position of the proximal vascular bundle of the latissimus dorsi flap make it a reliable and versatile flap. Occasional anatomic variations exist but usually do not preclude the use of this flap to reconstruct chest wall defects [16]. Patients with previous breast cancer and radionecrosis have usually had irradiation of the axilla and the breast, but this treatment does not increase the risk of complications with the latissimus dorsi flap [5]. Furthermore, the latissimus dorsi flap can be used even if the thoracodorsal vessels have been divided, as there can be retrograde blood supply through the branches to the serratus anterior or through other accessory branches [17]. Seroma formation is the most common minor complication after the use of a latissimus dorsi musculocutaneous flap. Using mattress sutures to close the wound can prevent this. More importantly, the functions of the upper limb and of respiration are not significantly altered by the preparation of this flap [18, 19]. This is not the case with other types of flaps, most notably the rectus abdomini and omental flaps, which cause some degree of respiratory compromise as a result of the abdominal incision. In summary, this method allows a single-stage reconstruction of a full-thickness defect of an infected segment of the chest wall using only well-vascularized autologous tissue. This technique provides a stable and esthetically pleasing result, which preserves chest wall integrity without the use of foreign material or devascularized tissue in an infected and irradiated operative field. References 1. Downey RJ, Rusch V, Hus FI. Chest wall resection for locally recurrent breast cancer: is it worthwhile? J Thorac Cardiovasc Surg 2000;119: Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg 1996;98: Lardinois D, Müller M, Furrer M, et al. Functional assessment of chest wall integrity after methylmethacrylate reconstruction. Ann Thorac Surg 2000;69: Lee RB, Miller JI. Radionecrosis and infection. In: Pearson FG, Deslauriers A, Ginsberg RJ, Hiebert CA, McKneally MF,

5 1724 RAFFOUL ET AL Ann Thorac Surg RECONSTRUCTION OF INFECTED FULL-THICKNESS CHEST WALL DEFECTS 2001;72: Urschel HC, eds. Thoracic surgery. New York: Churchill Livingston, 1995: Larson DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest wall defects: an experience with 50 patients. Plast Reconstr Surg 1984;73: Banic A, Ris HB, Erni D, Striffeler H. Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum. Ann Thorac Surg 1995;60: Morgan RF, Edgerton MT, Wanebo HJ, Daniel TM, Spotnitz WD, Kron IL. Reconstruction of full thickness chest wall defects. Ann Surg 1988;207: Mathes SJ. Chest wall reconstruction. Clin Plast Surg 1995; 22: Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg 1980;65: Watson WS, James AG. Fascia lata grafts for chest wall defects. J Thorac Surg 1947;16: Bisgard JD, Swenson SA. Tumors of the sternum: report of a case with special operative technique. Arch Surg 1948;56: Bobin JY, Crozet B, Ranchere JY. Using the costal muscle flap with latissimus dorsi muscle to repair full thickness anterior chest wall defects. Plast Reconstr Surg 1988;20: Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg 1979;63: Zancolli E, Mitze H. Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg 1973;55A: Ramirez OM, Ramasatry SS, Granick MS, Pang D, Futrell JW. New surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg 1987;80: Bartlett SP, May JW, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981;67: Fisher J, Bostwick J, Powell. Latissimus dorsi blood supply after thoracodorsal vessel division: the serratus collateral. Plast Reconstr Surg 1983;72: Laitung JKG, Peck F. Shoulder function after the loss of the latissimus dorsi. Br J Plast Surg 1985;38: Widmer MK, Krueger T, Lardinois D, Banic A, Ris HB. A comparative evaluation of intrathoracic latissimus dorsi and serratus anterior muscle transposition. Eur J Cardiothorac Surg 2000;18:435 9.